MEDICINE NOTES

COMMON HEADACHE SYNDROMES

1.) Vascular headache - a group of headache syndromes, of unknown cause ,in which pain results
from dilation of one or more of branches of carotid arteries.
Migraine headache and cluster headache account for the majority of the cases.
1. MIGRAINE
migraine headache is a benign and episodic disease, characterized by headache, nausea,
vomiting and/ or other symptoms of neurological dysfunction.
most common cause of vascular headache, approximately affects 15% of women and 6% men
usually begins in childhood or young adult life.
Etiology: the cause of migraine is often unknown, but several common precipitants have been
observed.
Precipitants
1) Family history of migraine present in nearly 2/3 of patients.
2) Environmental, dietary and psychological factors.
 Emotional stress, depression
 Altered sleep pattern or sleep deprivation
 Menses, Oral contraceptives
 Alcohol intake especially red wine
 Caffeine withdrawal
 Various food staffs ( e.g. . chocolates, nuts, aged , cheese , meals containing nitrates,
red wine)
 Perfumes
3) It may develop after seemingly minor head injury.

Pathogenesis: theories

1) Vascular theory: in this theory it is said that migraine and neurological symptoms are results of
extracranial vasodilatation and intracranial vasoconstriction.
2) Neuronal theory: a slowly spreading neuronal depolarization is considered as a cause
3) Trigeminovascular system abnormality: this theory says dysfunction of trigeminal nucleus
caudalis leads to release of vasoactive neuropeptides resulting in migraine.

Clinical features of migraine

It is relieved by sleep and exhilaration, Sumatriptan and pregnancy.

The syndrome of Classical migraine has five phases:

1. Prodromal phase: characterized by lassitude, irritability difficulty in concentrating

2. Aura phase: patients with aura often report visual complaints, vertigo, aphasia or other
neurological deficit before the onset of the headache
3. Headache phase – characteristic migraine headache
4. Headache termination – usually occurs within 24 hours
5. Post headache phase – feeling of fatigue. Sleepiness and irritability
 Characteristic Migraine head ache is:

● Moderate to severe head pain , pulsating quality often unilateral ( affecting half part of the
head )

● It is exacerbated by physical activity and relived by sleeping

● It is often associated with Nausea and/or vomiting, photophobia, phonophobia/ sonophobia

(dislike ad avoidance of laud sounds or noises).

● Multiple attacks may occur, each lasting 4 – 72 hrs.

There are different variants of Migraine

a) Common migraine
No focal neurological disturbance precedes the recurrent headache, the commonest
variation of migraine headache
b) Classic migraine
It is associated with characteristic premonitory sensory, motor or visual symptoms. Most
common symptoms reported are visual which include scotomas (a partial loss of vision or blind
spot in an otherwise normal visual field) and/or hallucinations. Classic migraine is migraine with
aura.
c) Complicated migraine
Migraine associated with dramatic transient neurological deficit, or a migraine attack that
leaves a persisting residual neurological deficit.

Treatment
Therapy should first involve removal of inciting agents when possible.
1. Acute/abortive treatment of migraine
a) NSAIDS (Nonsteroidal anti-inflammatory agents): such as ASA, paracetamol, Ibuprofen,
Diclofenac may reduce the severity and duration of migraine attack. These drugs are
effective for mild to moderate attacks and are most effective when taken early. Side
effects: Dyspepsia and GI irritation are common side effects
b) 5-Hydroxytryptophan-1 Agonists: is a serotonin agonist that decreases substance P
release at the trigeminovascular junction. (Naturally occurring amino acid and is a
precursor to the neurotransmitter serotonin.)
i. Nonselective (Ergot preparations: Ergotamine and dihydro-ergotamine )
Widely used for relief of acute attacks. Has oral, sublingual, rectal, nasal and parentral
preparation. Parentral forms are used for rapid relief of the attack. Usually prepared
combined with caffeine which potentiates the effect by improving absorption. Dose:
Initial dose: 1 – 2 mg oral /SL/ rectal and repeat every hour if there is no relief of
headache to a maximum of 6 – 8 mg over 24 hrsSide effects: are nausea, vomiting,
myalgias, chest discomfort, peripheral ischemia and even angina. Excess use may lead to
rebound headache and dependency
Contraindication: patients with vascular diseases like coronary heart disease
ii. Selective - Triptans including (Naratriptan, Ritatriptan, Sumatriptan, and
Zolmitriptan): are new drugs in management of migraine.
 Sumatriptan – single 6 mg SC dose is effective in 70 – 80% of patients
c) Dopamine agonists: are used as adjunctive therapy.
2. Prophylactic Treatment: includes drug regimens and changes in patients behavior
3. Calcitonin gene-related peptide receptor: Erenumab and Fremanezumab
Medical therapy:
• These are drugs that have capacity to stabilize migraine. Prophylactic treatment is
indicated if the patient has three or more attacks per month.
• Drugs used for this purpose include β-blockers (propranolol), Tricyclic antidepressants
(amitriptyline), and Calcium channel blockers (Verapamil), Valproic acid.
• Start with low dose and gradually increase if there is no adequate response.
Biofeedback therapy
It is simple and cost effective. It lessens migraine attacks by helping patients deal more
effectively with stress

2. CLUSTER HEADACHE

• Cluster head ache is a vascular headache syndrome, characterized by severe, acute headache that
occurs in clusters lasting several weeks followed by pain free intervals that averages a year.

• Common in men than women. Male: Female ratio is 8:1

• Usually begins 3rd to 6th decades

• Cluster headache is periorbital less commonly temporal. It has rapid onset without warning. It is also
severe and explosive in quality lasting 30 min to 2hrs, subsiding abruptly.

• Clusters characteristically occur in the spring and fall several times a day particularly at night and stay
for 3 – 8 weeks

• During attack patients often have associated nasal stuffiness, lacrimation and redness of the eye
ipsilateral to the headache.

• Alcohol provokes attacks in about 70% of patients

Treatment

Acute attack /abortive therapy (Treatment)

• Inhalation of 100% oxygen (Research has shown that oxygen causes a decrease in cerebral blood flow
in the brain, resulting in reduced pain) and

• Sumatriptan 6 mg S.C. stat said to be helpful and ergotamine or other analgesics may also be used.

Preventions/prophylactic therapy: clusters attacks can be prevented effectively by:

• Prednisolone, Lithium, Methysergide, Ergotamine, Sodium valproate and verapamil

3. TENSION HEADACHE

• Most common cause of headache in adults

• Common in women than men

• Can occur at any age, but onset during adolescence or young adulthood is common.

Etiology: various precipitating factors may cause tension headache in susceptible individual including.

• Stress – usually occurs in the afternoon after long stressful work hours

• Sleep deprivation

• Uncomfortable stressful position and/or bad posture

• Hunger (Irregular meal time)

• Eye strain resulting from continuous TV watching, working on computer screen for a long time.

Clinical feature

• Tension headache is characterized by mild or moderate, bilateral pain. Headache is a constant, tight,
pressing or band like sensation in the frontal, temporal, occipital or parietal area.

• Usually lasts less than 24 hrs but can persist for days or weeks.

• Prodromal symptoms are absent some patients have neck, jaw or temporomandibular joint
discomfort.

• On examination some patients may have tender spots in the pericranial or cervical muscles.

Treatment: management of tension headache consists:-

1. Pharmacotherapy

• Abortive therapy/acute treatment

● Stop or reduce severity of individual attacks

● This can be done with simple analgesics like paracetamol, ASA, Ibuprofen, and

● Diclofenac. If treatment is unsatisfactory addition of caffeine or other analgesic is beneficial.

• Long term preventive therapy

Main form of therapy for chronic form of tension headache

This kind of treatment is indicated if the headache is:

● Frequent (> 2 attacks / week ),

● Of long duration (> 3hrs)

● Severe (cause significant disability)

● Associated with overuse of abortive medication

Commonly used drug for long term treatment is Amitryptilline (10-75mg), fluoxetine [Prozac],
paroxetine [Paxil].

2. Physical Therapy: different techniques can be used including

● Hot or cold application

● Positioning

● Stretching exercises

● Traction

● Massage

3. Psychological Therapy

• Includes reassurance, Counseling, relaxation, stress management programs and biofeedback

techniques reduce both the frequency and severity of chronic headache.

4. HEADACHE ASSOCIATED WITH BRAIN TUMOR

• About 30% of patients with brain tumor present with headache.

• Brain tumor can affect all ages and both sexes. Headache of brain tumor is usually intermittent dull
aching, moderate intensity which worsens with time. It disturbs sleep in about 10% of patients,
exacerbated by exertion and postural changes. With time patients can develop nausea and vomiting.

• Upon examination focal neurological deficit may be detected.

E) Temporal Arteritis

• It is also called giant cell arteritis. It is an inflammatory disorder of the carotid artery and its branches.

• It is common in elderly, and women account for 65% of cases.

Clinical feature

• Typical presenting symptom includes headache, polymyalgia rheumatica (inflammatory disease of

muscle), jaw claudication (pain associated with chewing), fever and weight loss.

• Headache is located to temporal or occipital area, described as dull and boring. It is usually worse at
night and is often aggravated by exposure to cold.

• Scalp tenderness is often found over temporal artery.

• 50% of patients with untreated temporal arteritis develop blindness due to involvement of ophthalmic
artery and its branches

Diagnosis

• ESR is often elevated.

• Biopsy of temporal artery confirms the diagnosis.

Treatment

• Prednisolone 80 mg /day for 4 – 6 weeks

F) Lumbar Puncture headache

• Occurs in 10 – 30% of patients having LP

• Usually begins within 1 – 2 days and persists for 3 – 4 days.

• Headache of lumbar puncture is usually bifrontal or occipital, dull aching aggravated by sitting or
standing, head shaking, jugular vein compression and disappears in prone or supine position.

• Treatment: simple analgesics and lie the patient supine.